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<title>Retrenchment claim form HTML 20130514</title>
<meta name="title" content="Retrenchment claim form HTML 20130514">
<meta name="author" content="Willie Visagie">
<meta name="description" content="Modified by Willie Visagie on 14052013 as per File &quot;Updated Bug List 08052013.">
<meta name="keywords" content="Modified by Willie Visagie on 14052013 as per File &quot;Updated Bug List 08052013. , created by TeleForm 10.7 (10705) with Electric Paper HTML Plus&#178; Forms 5.0.220 , TeleForm HTML Plus&#178; Forms Electric Paper Informationssysteme GmbH, http://www.electricpaper.de" > 
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<form name='HtmlPlusForms' id='HPFsubmit' action='http://2008-4.quantumsolutions.co.za/dcASP/dcsubmit.aspx' onSubmit='return ep_submit();' method='post' accept-charset='UTF-8 ISO-8859-1 ISO-8859-2'>
<input type=hidden name='@STORE'>
<input type=hidden name='@BRWSVAR'>
<input type=hidden name='@BRWSVER'>
<input type=hidden name='@BRWSPTF'>
<input type=hidden name='@FORMID' value='40006'>
<input type=hidden name='@AJAX'>
<input type=hidden name='@OPENEX'>
<input type=hidden name='@ACROVAR'>
<input type=hidden name='@SUBMITURL'>
<input type=hidden name='@FORMDATA'>
<input type=hidden name='@FORMURL'>
<input type=hidden name='@FORMHEADER'>
<input type=hidden name='@FORMLASTMOD'>
<input type=hidden name='@RESPONSEURL' value=''>
<input type=hidden name='@RESPONSEMSG'>
<input type=hidden name='@RESPONSEERR'>
<input type=hidden name='@LOOKUP'>
<input type=hidden name='@LOOKUPDONE'>
<input type=hidden name='BacnkCode' value=''>
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<div class='div_rect_11'><img src='RetrenchmentClaim/40006001.png' width='161' height='73' alt='picture '>
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<div class='div_text1'> <span style='font:  bold 10pt "Arial";color:#000000;text-decoration:none;'>RETRENCHMENT CLAIM FORM <br /></span></div>
<div class='div_line_20'></div>
<div class='div_text2'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>PERSONAL PARTICULARS <br /></span></div>
<p /><label for='f27' class='clslbl'>Policy Number</label>
<input type=TEXT value='' class='f27' id='f27' name='PolicyNumber' tabindex=1 title="Policy Number" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,16);' onKeyDown = 'maxl(this,16);return EP_OKD(this ,event);'>
<p /><label for='f28' class='clslbl'>Claimant ID Number</label>
<input type=TEXT value='' class='f28' id='f28' name='IDNumber' tabindex=2 title="Claimant ID Number" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,13);' onKeyDown = 'maxl(this,13);return EP_OKD(this ,event);'>
<div class='div_text3'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Policy number <br /></span></div>
<div class='div_text7'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>ID number <br /></span></div>
<p /><label for='f32' class='clslbl'>First name(s) of claimant</label>
<input type=TEXT value='' class='f32' id='f32' name='First_Names' tabindex=3 title="First name(s) of claimant" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,28);' onKeyDown = 'maxl(this,28);return EP_OKD(this ,event);'>
<div class='div_text4'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>First name(s) of claimant <br /></span></div>
<p /><label for='f35' class='clslbl'>Claimant's surname</label>
<input type=TEXT value='' class='f35' id='f35' name='Surname' tabindex=4 title="Claimant&#39;s surname" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,31);' onKeyDown = 'maxl(this,31);return EP_OKD(this ,event);'>
<div class='div_text5'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Claimant&#39;s surname <br /></span></div>
<p /><label for='f37' class='clslbl'>Date policy commenced</label>
<input type=TEXT value='' class='f37' id='f37' name='Datepolicycommenced' tabindex=5 title="Date policy commenced" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<div class='div_text6'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Date policy commenced <br /></span></div>
<div class='div_text13'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(ddmmyyyy) <br /></span></div>
<p /><label for='f41' class='clslbl'>Income Tax office</label>
<input type=TEXT value='' class='f41' id='f41' name='DITaxOffice' tabindex=6 title="Income Tax office" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,12);' onKeyDown = 'maxl(this,12);return EP_OKD(this ,event);'>
<p /><label for='f42' class='clslbl'>Income Tax reference number</label>
<input type=TEXT value='' class='f42' id='f42' name='DITaxno' tabindex=7 title="Income Tax reference number" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,12);' onKeyDown = 'maxl(this,12);return EP_OKD(this ,event);'>
<div class='div_text9'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Income tax office <br /></span></div>
<div class='div_text8'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Income tax reference number <br /></span></div>
<p /><label for='f46' class='clslbl'>Address Line 1</label>
<input type=TEXT value='' class='f46' id='f46' name='Address_Line_1' tabindex=8 title="Address Line 1" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text16'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Line 1 <br /></span></div>
<p /><label for='f48' class='clslbl'>Address_Line_2</label>
<input type=TEXT value='' class='f48' id='f48' name='Address_Line_2' tabindex=9 title="Address_Line_2" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text17'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Line 2 <br /></span></div>
<div class='div_text21'> <span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Address of </span><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>claimant <br /> </span></div>
<p /><label for='f53' class='clslbl'>Suburb</label>
<input type=TEXT value='' class='f53' id='f53' name='Suburb' tabindex=10 title="Suburb" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 1);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text18'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Suburb <br /></span></div>
<p /><label for='f55' class='clslbl'>Town</label>
<input type=TEXT value='' class='f55' id='f55' name='Town' tabindex=11 title="Town" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,32);' onKeyDown = 'maxl(this,32);return EP_OKD(this ,event);'>
<div class='div_text19'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Town <br /></span></div>
<p /><label for='f57' class='clslbl'>Postal Code</label>
<input type=TEXT value='' class='f57' id='f57' name='Code' tabindex=12 title="Postal Code" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<div class='div_text20'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Code <br /></span></div>
<p /><label for='f64' class='clslbl'> Home Telephone Number</label>
<input type=TEXT value='' class='f64' id='f64' name='Home_Number' tabindex=13 title=" Home Telephone Number" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,10);' onKeyDown = 'maxl(this,10);return EP_OKD(this ,event);'>
<p /><label for='f65' class='clslbl'> Work Phone Number</label>
<input type=TEXT value='' class='f65' id='f65' name='Work_Number' tabindex=14 title=" Work Phone Number" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,10);' onKeyDown = 'maxl(this,10);return EP_OKD(this ,event);'>
<p /><label for='f66' class='clslbl'> Cell Number</label>
<input type=TEXT value='' class='f66' id='f66' name='Cell_Number' tabindex=15 title=" Cell Number" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,10);' onKeyDown = 'maxl(this,10);return EP_OKD(this ,event);'>
<div class='div_text14'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Tel (h) <br /></span></div>
<div class='div_text15'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Tel (w) <br /></span></div>
<div class='div_text22'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Cell <br /></span></div>
<div class='div_line_72'></div>
<div class='div_text31'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>EMPLOYMENT DETAILS <br /></span></div>
<div class='div_text32'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Name of employer (from whom you were retrenched) <br /></span></div>
<p /><label for='f75' class='clslbl'>Name of Employer (from whom you were retrenched)</label>
<textarea class='f75' id='f75' name='Employer' spellcheck='false' tabindex=16 title="Name of Employer (from whom you were retrenched)" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f76' class='clslbl'>Position held</label>
<textarea class='f76' id='f76' name='RPosition' spellcheck='false' tabindex=17 title="Position held" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 1);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<div class='div_text33'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Position held <br /></span></div>
<p /><label for='f80' class='clslbl'>Date of joining this employer</label>
<input type=TEXT value='' class='f80' id='f80' name='DOE' tabindex=18 title="Date of joining this employer" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<p /><label for='f81' class='clslbl'>Date last actively worked</label>
<input type=TEXT value='' class='f81' id='f81' name='DOA' tabindex=19 title="Date last actively worked" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<div class='div_text34'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Date of joining this employer <br /></span></div>
<div class='div_text30'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Date last actively worked <br /></span></div>
<div class='div_text45'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(ddmmyyyy) <br /></span></div>
<div class='div_text44'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(ddmmyyyy) <br /></span></div>
<p /><label for='f87' class='clslbl'>Date last salary payable</label>
<input type=TEXT value='' class='f87' id='f87' name='DOS' tabindex=20 title="Date last salary payable" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<div class='div_text35'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Date last salary payable <br /></span></div>
<div class='div_text46'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(ddmmyyyy) <br /></span></div>
<p /><label for='f95' class='clslbl'>What would have been your normal date of retirement, had you not been retrenched?</label>
<input type=TEXT value='' class='f95' id='f95' name='DOR' tabindex=21 title="What would have been your normal date of retirement, had you not been retrenched?" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<div class='div_text36'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>What would have been your normal date of retirement had you not been retrenched? <br /></span></div>
<div class='div_text47'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(ddmmyyyy) <br /></span></div>
<p /><label for='f99' class='clslbl'>When were you advised of your pending retrenchment?</label>
<input type=TEXT value='' class='f99' id='f99' name='Date_of_event' tabindex=22 title="When were you advised of your pending retrenchment?" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<div class='div_text37'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>When were you advised of your pending retrenchment? <br /></span></div>
<div class='div_text48'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(ddmmyyyy) <br /></span></div>
<p /><label for='f103' class='clslbl'>How many employees were retrenched at the time you were retrenched?</label>
<input type=TEXT value='' class='f103' id='f103' name='ReNumber' tabindex=23 title="How many employees were retrenched at the time you were retrenched?" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,5);' onKeyDown = 'maxl(this,5);return EP_OKD(this ,event);'>
<div class='div_text38'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>How many employees were retrenched at the time you were retrenched? <br /></span></div>
<div class='div_text39'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Reason for retrenchment <br /></span></div>
<p /><label for='f111' class='clslbl'>Reason for Retrenchment</label>
<textarea class='f111' id='f111' name='ReasonforRetrenchment' spellcheck='false' tabindex=24 title="Reason for Retrenchment" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,200);' onKeyDown = 'maxl(this,200);return EP_OKD(this,event);' ></textarea>
<div class='div_text41'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Name of immediate manager (at date of retrenchment) <br /></span></div>
<p /><label for='f122' class='clslbl'>Name of immediate manager (at date of retrenchment)</label>
<input type=TEXT value='' class='f122' id='f122' name='ManagersName' tabindex=25 title="Name of immediate manager (at date of retrenchment)" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,34);' onKeyDown = 'maxl(this,34);return EP_OKD(this ,event);'>
<p /><label for='f128' class='clslbl'>Contact details of this manager - Work Phone Number</label>
<input type=TEXT value='' class='f128' id='f128' name='ADTelWork' tabindex=26 title="Contact details of this manager - Work Phone Number" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,10);' onKeyDown = 'maxl(this,10);return EP_OKD(this ,event);'>
<div class='div_text40'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Tel (w) <br /></span></div>
<div class='div_text42'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Contact details of this manager <br /></span></div>
<p /><label for='f133' class='clslbl'>Contact details of this manager - Email Address</label>
<textarea class='f133' id='f133' name='EmpEmail' spellcheck='false' tabindex=27 title="Contact details of this manager - Email Address" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 1);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<div class='div_text43'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Email address <br /></span></div>
<div class='div_line_135'></div>
<div class='div_text23'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>PREVIOUS WORK HISTORY (for the past year) <br /></span></div>
<div class='div_text24'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Previous employer <br /></span></div>
<p /><label for='f138' class='clslbl'>Previous employer</label>
<input type=TEXT value='' class='f138' id='f138' name='EmpName' tabindex=28 title="Previous employer" spellcheck='false' onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,34);' onKeyDown = 'maxl(this,34);return EP_OKD(this ,event);'>
<p /><label for='f139' class='clslbl'>Position held at previous employer</label>
<textarea class='f139' id='f139' name='RPosition_2' spellcheck='false' tabindex=29 title="Position held at previous employer" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 1);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<div class='div_text25'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Position held <br /></span></div>
<p /><label for='f141' class='clslbl'>Date of joining previous employer</label>
<input type=TEXT value='' class='f141' id='f141' name='DOJE' tabindex=30 title="Date of joining previous employer" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<p /><label for='f142' class='clslbl'>Last working day at previous employer</label>
<input type=TEXT value='' class='f142' id='f142' name='DOLWD' tabindex=31 title="Last working day at previous employer" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<div class='div_text26'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Date of joining this employer <br /></span></div>
<div class='div_text27'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Last working day <br /></span></div>
<div class='div_text50'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(ddmmyyyy) <br /></span></div>
<div class='div_text49'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(ddmmyyyy) <br /></span></div>
<input type=CHECKBOX class='f147' id='f147' name='DSSE_2:0' value='1' tabindex=54 title="Please attach a copy of your certificate of service. - 1" onfocus='hAI(this);' onclick="bAI(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event); ' onkeydown = 'return EP_OKD(this,event);'  DISABLED>
<p /><label for='f147' class='clslbl'>Please attach a copy of your certificate of service. - 1</label>
<div class='div_text28'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Please attach a copy of your certificate of service. <br /></span></div>
<div class='div_text29'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'> <br /></span></div>
<div class='div_line_150'></div>
<div class='div_text11'><div align='left'><span style='font: normal normal 7pt Arial;color:#000000;text-decoration: none'>Nedgroup Life Assurance Company Limited .Reg No 1993/001022/06 <br /></span></div><div align='left'><span style=''>1st Floor, Ridgeside Campus, 2 Ncondo Drive, Umhlanga Rocks, 4320 ; PO Box 149175, East End, 4018. <br /></span></div><div align='left'><span style=''>Tel 0860 263 543 Fax 0860 065 437 Website www.nedgrouplife.co.za. <br /></span></div></div>
<div class='div_line_154'></div>
<div class='div_text12'><div align='left'><span style='font: normal normal 7pt Arial;color:#000000;text-decoration: none'>We support resolution for unresolved disputes via the Ombudsman for Long-term insurance. We are an authorised financial services provider (licence number 40915). <br /></span></div><div align='left'><span style=''>We are a registered credit provider in terms of the National Credit Act (NCR Reg No NCRCP61) . <br /></span></div><div align='left'><span style=''> <br /></span></div></div>
<div class='div_line_156'></div>
<div class='div_text10'><span style='font: 7pt "Arial";color:#000000;text-decoration:none;'>Page 1 of 2 <br /></span></div>
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<div class='div_line_13'></div>
<p /><label for='f14' class='clslbl'>PolicyNumber_2</label>
<input type=TEXT value='' class='f14' id='f14' name='PolicyNumber_2' tabindex=32 title="PolicyNumber_2" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,16);' onKeyDown = 'maxl(this,16);return EP_OKD(this ,event);'>
<p /><label for='f15' class='clslbl'>IDNumber_2</label>
<input type=TEXT value='' class='f15' id='f15' name='IDNumber_2' tabindex=33 title="IDNumber_2" spellcheck='false' onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 0);bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,13);' onKeyDown = 'maxl(this,13);return EP_OKD(this ,event);'>
<div class='div_text53'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Policy number <br /></span></div>
<div class='div_text54'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>ID number <br /></span></div>
<div class='div_line_18'></div>
<div class='div_text55'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>GENERAL HISTORY/OTHER PARTICULARS <br /></span></div>
<div class='f22_box'></div><p /><label for='f22' class='clslbl'>Have you taken any sick-leave over the past two years? - 1</label>
<input type=RADIO class='f22' id='f22' name='DSSE_3' value='1' tabindex=34 title="Have you taken any sick-leave over the past two years? - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f23_box'></div><p /><label for='f23' class='clslbl'>Have you taken any sick-leave over the past two years? - 2</label>
<input type=RADIO class='f23' id='f23' name='DSSE_3' value='2' tabindex=34 title="Have you taken any sick-leave over the past two years? - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='div_text57'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>YES <br /></span></div>
<div class='div_text58'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>NO <br /></span></div>
<div class='div_text56'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Have you taken any sick-leave over the past two years? <br /></span></div>
<div class='div_text59'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>If so, for how long on each occasion and for what medical reason? <br /></span></div>
<p /><label for='f34' class='clslbl'> If so, for how long on each occasion and for what medical reason?</label>
<textarea class='f34' id='f34' name='TakenLeaveYes' spellcheck='false' tabindex=35 title=" If so, for how long on each occasion and for what medical reason?" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,100);' onKeyDown = 'maxl(this,100);return EP_OKD(this,event);' ></textarea>
<div class='div_text61'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>What is your current medical status? <br /></span></div>
<p /><label for='f45' class='clslbl'>What is your current medical status?</label>
<textarea class='f45' id='f45' name='CurrentMedStatus' spellcheck='false' tabindex=36 title="What is your current medical status?" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,100);' onKeyDown = 'maxl(this,100);return EP_OKD(this,event);' ></textarea>
<div class='div_text60'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Should you be taking any chronic medication or undergoing any regular medical or paramedical treatment, please provide details: <br /></span></div>
<p /><label for='f52' class='clslbl'>Should you be taking any chronic medication or undergoing any regular medical or paramedical treatment, please provide details</label>
<textarea class='f52' id='f52' name='TakenLeaveYes_4' spellcheck='false' tabindex=37 title="Should you be taking any chronic medication or undergoing any regular medical or paramedical treatment, please provide details" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,100);' onKeyDown = 'maxl(this,100);return EP_OKD(this,event);' ></textarea>
<div class='f59_box'></div><p /><label for='f59' class='clslbl'>Have you taken part in any labour action? - 1</label>
<input type=RADIO class='f59' id='f59' name='AnyLabourAction' value='1' tabindex=38 title="Have you taken part in any labour action? - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f60_box'></div><p /><label for='f60' class='clslbl'>Have you taken part in any labour action? - 2</label>
<input type=RADIO class='f60' id='f60' name='AnyLabourAction' value='2' tabindex=38 title="Have you taken part in any labour action? - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='div_text63'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>YES <br /></span></div>
<div class='div_text64'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>NO <br /></span></div>
<div class='div_text62'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Have you taken part in any labour action (ie voluntary strike, wage disputes, etc) over the past 12 months? <br /></span></div>
<div class='div_text65'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>If answer is YES, please provide details: <br /></span></div>
<p /><label for='f71' class='clslbl'> If answer is YES, please provide details of Labour Action</label>
<textarea class='f71' id='f71' name='ReasonforRetrenchment_2' spellcheck='false' tabindex=39 title=" If answer is YES, please provide details of Labour Action" onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,255);' onKeyDown = 'maxl(this,255);return EP_OKD(this,event);' ></textarea>
<div class='div_text66'> <span style='font:  bold 8pt "Arial";color:#000000;text-decoration:none;'>Please ensure that you attach a copy of your original letter of appointment to your company, as well as a copy of a statement from your employer confirming your retrenchment. <br /></span></div>
<input type=CHECKBOX class='f79' id='f79' name='AnyLabourAction_2:0' value='1' tabindex=65 title="Was the deceased a scholar/student/employed? - 1" onfocus='hAI(this);' onclick="bAI(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event); ' onkeydown = 'return EP_OKD(this,event);'  DISABLED>
<p /><label for='f79' class='clslbl'>Was the deceased a scholar/student/employed? - 1</label>
<div class='div_text67'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'> <br /></span></div>
<div class='f90_box'></div><p /><label for='f90' class='clslbl'>Have you been offered any position(s) - 1</label>
<input type=RADIO class='f90' id='f90' name='AnyOffers' value='1' tabindex=40 title="Have you been offered any position(s) - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f91_box'></div><p /><label for='f91' class='clslbl'>Have you been offered any position(s) - 2</label>
<input type=RADIO class='f91' id='f91' name='AnyOffers' value='2' tabindex=40 title="Have you been offered any position(s) - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='div_text69'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>YES <br /></span></div>
<div class='div_text70'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>NO <br /></span></div>
<div class='div_text68'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Have you been offered any position(s)? <br /></span></div>
<div class='div_text74'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>If YES, please supply details: <br /></span></div>
<p /><label for='f102' class='clslbl'> Details of offered position.</label>
<textarea class='f102' id='f102' name='AnyOffersYes_1' spellcheck='false' tabindex=41 title=" Details of offered position." onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,100);' onKeyDown = 'maxl(this,100);return EP_OKD(this,event);' ></textarea>
<div class='f106_box'></div><p /><label for='f106' class='clslbl'>Have you accepted a position with any company? - 1</label>
<input type=RADIO class='f106' id='f106' name='AcceptOffer' value='1' tabindex=42 title="Have you accepted a position with any company? - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f107_box'></div><p /><label for='f107' class='clslbl'>Have you accepted a position with any company? - 2</label>
<input type=RADIO class='f107' id='f107' name='AcceptOffer' value='2' tabindex=42 title="Have you accepted a position with any company? - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='div_text72'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>YES <br /></span></div>
<div class='div_text73'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>NO <br /></span></div>
<div class='div_text71'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Have you accepted a position with any company? <br /></span></div>
<div class='div_text77'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>If YES, please supply the name of the company: <br /></span></div>
<p /><label for='f113' class='clslbl'> Details of accepted position.</label>
<textarea class='f113' id='f113' name='AcceptOfferyesCoName' spellcheck='false' tabindex=43 title=" Details of accepted position." onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA + EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f114' class='clslbl'> Contact Person at Accepted position.</label>
<textarea class='f114' id='f114' name='AcceptedOfferContactperson' spellcheck='false' tabindex=44 title=" Contact Person at Accepted position." onfocus='hAI(this);' onblur="EP_CF(this,1);EP_VAL( this, 'EP_ALPHA', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<p /><label for='f115' class='clslbl'> Contact Number of Contact person at accepted position.</label>
<input type=TEXT value='' class='f115' id='f115' name='AcceptedOfferContactno' tabindex=45 title=" Contact Number of Contact person at accepted position." spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,10);' onKeyDown = 'maxl(this,10);return EP_OKD(this ,event);'>
<div class='div_text75'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Contact person <br /></span></div>
<div class='div_text78'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Contact no <br /></span></div>
<p /><label for='f119' class='clslbl'> Date Employements will commence</label>
<input type=TEXT value='' class='f119' id='f119' name='AcceptOfferComDate' tabindex=46 title=" Date Employements will commence" spellcheck='false' onfocus='hAI(this);' onblur="bAI(this);epelall();" onkeypress = 'return noe(this, event);' onKeyUp = 'maxl(this,8);' onKeyDown = 'maxl(this,8);return EP_OKD(this ,event);'>
<div class='div_text79'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Date of commencement of employment <br /></span></div>
<div class='div_text83'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>(ddmmyyyy) <br /></span></div>
<div class='f123_box'></div><p /><label for='f123' class='clslbl'>Have you registered for UIF? - 1</label>
<input type=RADIO class='f123' id='f123' name='UIF' value='1' tabindex=47 title="Have you registered for UIF? - 1" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='f124_box'></div><p /><label for='f124' class='clslbl'>Have you registered for UIF? - 2</label>
<input type=RADIO class='f124' id='f124' name='UIF' value='2' tabindex=47 title="Have you registered for UIF? - 2" onfocus='hAI(this);' onclick="bAI(this);EPRT(this);" onchange="epelall();" onkeypress = 'return EP_OKD(this,event);return noe(this, event);' onkeydown = 'return EP_OKD(this,event);' >
<div class='div_text81'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>YES <br /></span></div>
<div class='div_text82'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>NO <br /></span></div>
<div class='div_text80'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;white-space: nowrap;'>Have you registered for UIF? <br /></span></div>
<p /><label for='f131' class='clslbl'> Please Supply UIF Number</label>
<textarea class='f131' id='f131' name='UIFno' spellcheck='false' tabindex=48 title=" Please Supply UIF Number" onfocus='hAI(this);' onblur="EP_VAL( this, 'EP_NUMERIC', 0);bAI(this);epelall();" onKeyUp = 'maxl(this,50);' onKeyDown = 'maxl(this,50);return EP_OKD(this,event);' ></textarea>
<div class='div_text76'><span style='font: 8pt "Arial";color:#000000;text-decoration:none;'>Please supply your UIF no <br /></span></div>
<div class='div_line_152'></div>
<div class='div_text52'><div align='left'><span style='font: normal normal 7pt Arial;color:#000000;text-decoration: none'>Nedgroup Life Assurance Company Limited .Reg No 1993/001022/06 <br /></span></div><div align='left'><span style=''>1st Floor, Ridgeside Campus, 2 Ncondo Drive, Umhlanga Rocks, 4320 ; PO Box 149175, East End, 4018. <br /></span></div><div align='left'><span style=''>Tel 0860 263 543 Fax 0860 065 437 Website www.nedgrouplife.co.za. <br /></span></div></div>
<div class='div_line_157'></div>
<div class='div_text51'><span style='font: 7pt "Arial";color:#000000;text-decoration:none;'>Page 2 of 2 <br /></span></div>
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